197607201-10-24-2022-11-AS-SCIS-CM426M-20221213160720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607201
Report Date: 10/24/2022
Date Signed: 10/24/2022 10:10:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20221020143110

FACILITY NAME:	GOLDEN CITY HOME CARE		FACILITY NUMBER:	197607201
ADMINISTRATOR:	ANTONIA DIONISIO		FACILITY TYPE:	740
ADDRESS:	2451 W. 230TH STREET		TELEPHONE:	(310) 325-1995
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 6	DATE:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	ANTONIA DIONISIO		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff not wearing mask while providing care inside the facility.

INVESTIGATION FINDINGS:

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On 10/24/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Administrator Antonia Dionisio. The facility is free of Covid-19 infection. LPA met with Staff Esperanza Bianez (S2) and Staff Jose Bactad (S3). Administrator Antonia Dionisio (S1) arrived shortly after and assisted LPA with the visit. LPA explained the purpose of the visit.

The investigation consisted of the following: LPA Lourdes Montoya toured the facility with S1 and S2. LPA observed three (3) staff and six (6) residents during the visit. LPA interviewed three (3) staff (S1-S3) and two residents (R1 and R2). LPA was not able to interview two residents (R3 and R4) due to their medical conditions and two other residents (R5 & R6) were sleeping. LPA interviewed one (1) witness.

REPORT CONTINUED IN LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20221020143110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CITY HOME CARE	FACILITY NUMBER: 197607201
	VISIT DATE: 10/24/2022

NARRATIVE

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Investigations revealed:

Allegation: Facility staff not wearing face covering while providing direct care to residents.

It is alleged that facility staff are not wearing a mask with a good fit while providing care to residents. Reporting Party stated “On 10/18/2022, 3/1/2022 and 12/1/2021, during an unannounced facility visit, facility caregivers were observed not wearing appropriate PPE when interacting with residents and providing direct care. Based on record reviews, PIN 22-28-ASC indicates that Adult and Senior Care Facilities follow the California Department of Public Health (CDPH) Masking Guidance dated September 20, 2022 which states “Masks are required for all individuals regardless of vaccination status in Adult and Senior Care Facilities”. Based on the department’s interview with the Administrator (S1), S1 had observed both full time caregivers (S2 and S3) who provide direct care to residents not wearing a mask while around with residents inside the facility. S1 stated S2 and S3 have been informed to wear a mask but they continued to refuse. Interview with S2 revealed sometimes S2 does not wear a mask while in the facility because S2 is not comfortable wearing a mask and she feels like having an allergy on her scalp. However, S2 admitted that she has no medical concerns in wearing a mask. S3 revealed during an interview that S3 sometimes forgets to wear a mask while working in the facility. Interview with a resident (R1) revealed staff were not wearing mask when she was just admitted but they have been wearing a mask recently. R2 refused to respond to LPA's questionnaire due to her medical condition while a witness (W1) thinks staff wear a mask in the facility. During LPA Montoya’s unannounced visit on 10/24/2022, LPA observed S2 and S3 not wearing a mask while working in the facility. Based on observation, interviews and record reviews, there is sufficient evidence to corroborate the above allegation.

Based on LPA's investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and Appeal Rights was discussed with Administrator Antonia Dionisio. A hard copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221020143110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN CITY HOME CARE	FACILITY NUMBER: 197607201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/31/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in all facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Adminstrator shall conduct in-service training to staff on PPE usage. Administrator shall submit a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 10/31/2022.
	8 9 10 11 12 13 14	Based on LPA's observations, interviews and record reviews, Direct care providers (S2 and S3) failed to wear a mask while providing care to residents. This poses a potential health, safety and/or personal rights risk to residents in care .	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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